The last drug that can fight gonorrhea is beginning to falter

To an unknown eye, the press release from the Massachusetts Department of Public Health two weeks ago looked rather routine. The language may have been a little unnerving, but carefully worded: Analysts had discovered a resident with a type of gonorrhea who showed “impaired response to multiple antibiotics,” but that person — and a second with a similar infection — had been cured.

To a citizen, the announcement may have felt like hitting a small wave in a boat: a moment of being off balance and then back to normal. For people in public health and medicine, it felt more like being in the know Titanic and spot the iceberg.

Here’s what the news basically said: A disease so old and basic we hardly think about it, though it affects nearly 700,000 Americans a year, is conquering the last antibiotics now available to treat it. If given the ability to bypass those drugs, our only options are desperate searches for others that haven’t yet been approved — or a throwback to a time when untreated gonorrhea caused crippling arthritis, made babies blind when they were born, and made men infertile by testicular damage and women from pelvic inflammatory disease.

The tiring thing for professionals is that they saw the iceberg coming. Gonorrhea is not like Covid, a new pathogen that took us by surprise and required heroic research efforts and medical care. It is a known foe, as old as recorded history, with a predictable response to treatment and an equally predictable record of acquiring antibiotic resistance.

Yet it is ahead of us. The discovery in Massachusetts “is alarming,” said Yonatan Grad, an infectious disease physician and researcher and associate professor at the Harvard T.H. Chan School of Public Health. “It’s confirmation of a trend we knew was happening. And it is expected to get worse.”

A little more detail on the announcement: The Massachusetts Department said the person had been diagnosed with a new strain of gonorrhea that carried a constellation of features never before detected in a single sample of bacteria in the US. Those traits include a genomic signature – previously seen in patients in the UK, Asia and one person in Nevada – called the A60 pen allele. But genomic analysis showed it also showed, for the first time, complete resistance to three antibiotics and some resistance to three more. One is the last resort in the US: an injectable cephalosporin antibiotic called ceftriaxone.

In 2020, the CDC stated that doctors should only administer ceftriaxone for gonorrhea because all other antibiotics used against the infection in the past had lost their effectiveness. Fortunately, the hefty dose recommended by the GGD still worked for this patient. It also healed the second person, who the health department says has no connection to the first and was carrying the same strain with the same resistance pattern. But to experts, that reduced sensitivity indicated that ceftriaxone could also be on the wane.

“This situation is both a warning and an opportunity,” said Kathleen Roosevelt, director of the Massachusetts Division of STD Prevention and HIV Surveillance, noting that the number of gonorrhea cases in the US is at an all-time high. To try to curb that trend, her agency sent instructions to every primary care professional in the state, asking them to extensively interview patients who test positive, encouraging those who have undergone treatment to come back to make sure they be cured… and, crucially, change the way clinics test patients for infection to begin with.

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